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Editorial: Change the rules on referrals to physician specialists

Patients can only see a specialist if they are referred by their family physician, and the need for additional referrals every six months serves only to render the system needlessly complex, our editorial board writes. THOMAS KIENZLE, THE ASSOCIATED PRESS

On a near-weekly basis, letters to this newspaper tell the story of family medicine in crisis. While there is much that cannot be resolved overnight, here is a suggestion that the minister in charge, Adrian Dix, may wish to consider. For it can be acted on, if not overnight, then in short order.

The issue has to do with the system for referring patients to a specialist. As it stands, in nearly every instance, patients can only see a specialist if they are referred by their family physician.

This rule goes back several decades. Originally it made sense.

Specialists are often in short supply. If any patient who wished could book an appointment without first seeing a family physician to determine need, specialists would be swamped.

Further, since specialist fees are often much higher than family doctors can bill, there would be a significant drain on the health-care budget if the requirement for a referral were removed.

There are two serious problems with this policy as things stand. First, what happens if a patient doesn’t have a family doctor, as is the case for one in three adults in B.C.?

Here’s what a panel, established to review the rules for referrals, recently advised:.

“For patients without a family physician, Pathways, the provincial public directory, has information about family physicians accepting new patients … Additional options include Urgent and Primary Care Centres (UPCCs), which provide access to same-day, urgent, non-emergency health care.”

Unfortunately, Pathways is too often a pathway to nowhere, because there are hardly any family doctors accepting new patients.

And many, if not most, UPCCs are seriously short-staffed. The clinics on Vancouver Island have only 39 per cent of the approved staff, and provincewide, only 20,000 patients are receiving ongoing care.

This is in no sense a solution to the referral roadblock.

The second problem with the current rules is that a patient who needs to see a specialist must get a repeat referral every six months. There are exceptions.

But in the main, a referral lasts only six months, and covers only one consult. In many cases this makes no medical sense.

What about patients with chronic conditions who need ongoing specialist care? In these circumstances, the specialist is intimately familiar with the patient’s clinical needs. Why, then, the requirement for additional referrals?

An unintended consequence comes with this rule. When specialists see a patient by referral, they can bill for a “consult,” which is to their financial advantage, since consult fees are at the top end of the range.

However, if the specialist agrees to see the patient a second or subsequent time without a further referral, this is deemed a “follow-up” visit, and the fee is far lower.

There is thus a financial incentive for specialists to require referrals every six months, even where there is no medical need. This rule is also in the interests of family doctors, who can bill for repeat referrals.

If readers gain the impression that these requirements have more to do with managing money than caring for patients, they would not be far wrong.

What, then, can be done? First, remove the requirement that referrals in the main last only six months.

Second, in fairness to physicians, make the fees for each “follow-up” visit equal to a consult. And ask the specialist to advise the patient’s family doctor, if there is one, that this arrangement has been made, so the latter can bill as if ongoing referrals were in place.

Third, expand the existing automated system that monitors over-billing, so that if specialists take undue advantage, their practice will be audited.

All of this can be done by the minister on his own authority. Nor need they be indefinite.

If in future adequate family medicine is restored, the original referral system can be reactivated.

But as things stand, that point is years away.